Why does Medicare deny reimbursement on a manual wheelchair that has been paid for and delivered months ago? The answer is simple: a power wheelchair CMN overrides a manual wheelchair CMN. The “system” pays for the power wheelchair while the manual wheelchair payment languishes.

Not every claim that goes to a Durable Medical Equipment Regional Carrier (DMERC) is reviewed by an actual person. There is a system of edits that the claim must proceed through before it hits the payment floor. The CMN drives payment for wheelchairs. There could be other reasons for the denial such as: a place-of-service issue, a break in service, or a change in primary insurance. These will be processed through the system.

The first rule to justify any type of wheelchair is to show that the patient is bed- or chair-confined without the chair and requires it to move around in her residence. The level of chair required is determined by the patient’s functional needs. This relates to the basic rule: Medicare pays for the least costly alternative for function of the malformed body member. Medicare pays for HME needed “in the home.”

The K0003 (for Lightweight manual chairs)
An order for the wheelchair must be received “before” dispensing any item to a Medicare beneficiary. The dispensing order can be written, verbal, or fax. You can bill from a faxed CMN, but it is always best to keep an original. The detailed written order can be the CMN, and where a CMN is required, most companies use this for the detailed written order. A CMN can be a dispensing order as well as long as it is dated prior to or on date of delivery.

A CMN indicating that the patient needs a wheelchair to move around in his residence (#1=Y) and the patient “can” and “does” self propel in a lightweight wheelchair (#8=N, #9=Y), and the number of hours the patient is up in the wheelchair—must be completed (question #5). If the questions are not answered correctly, the CMN will down code to a K0001.

What about K0004s?
Coverage for the K0004 (for high-strength lightweight manual wheelchairs) is slightly different than the coverage for the K0003. What is needed to get it to “process” through the system? A CMN is adequate if it indicates that the patient needs a wheelchair to move around in his residence (#1=Y) and needs a high-strength, lightweight wheelchair to self-propel (while engaging in frequent activities that cannot be performed in a lower-level chair [#8=N, #9=Y]), or the patient requires a seatdepth, width, or height that cannot be accommodated in a lower-level chair, (#8=N or D) (#9=N, Y, or D), and spends at least 2 hours per day in the wheelchair (question # 5). If the questions are not answered correctly, the CMN would down-code to a K0001. When it relates to the question #9 answer being N or D, you must put additional documentation in the HAO (narrative field) explaining why a lower-level chair would not meet the patient’s needs.

If question #1=Y and #8=Y, then this would down-code to a K0001. There would not be a down-code (by the system) from a K0004 to a K0003 unless the DMERC put in an edit to tell the system that if there is no additional documentation relating to the need for a K0004 over a K0003, down-code to the K0003. This is not systematically done over the four regions. K0004 wheelchairs do require a reason why they are needed over the K0003 or any lower-level chair. (This relates to the fact that Medicare pays for the least costly alternative for functional need within the home.)

There are other options if the patient “wants” a K0004 but “needs” a K0001. This is when you use the ABN (advanced beneficiary notice), or you can do a free upgrade (GL modifier) if this is the only base your company chooses to keep in stock. In that instance, you would use the code that meets the patient’s criteria for the CMN and 1500 form—adding the GL modifier indicating this is a free upgrade. You would put the name, make, and model of the item you actually provided in the HAO of an electronic claim—or in block 19 of the 1500 form of a paper claim.

Ultra Lightweight (K0005)
Ultra lightweights are inexpensive or routinely purchased—which means they can be purchased up front or rented until maximum payment has been met (usually 10 months). Coverage for the K0005 is determined on an individual-consideration basis. The K0005 can go to ADMC (Advanced Determination of Medicare Coverage). The modifier required is NU for purchase, but if it is rented, the only modifier is RR (do not use the capped rental modifiers on this base). Because it is in a different category, this base would be denied if billed as a purchase and it did not meet medical necessity criteria. There is no rule that a physical/occupational evaluation is “required” for this or any other wheelchair base at this time.

The information needed specifically for the K0005 is: an order for the ultra light base; a CMN with #1=Y, #8=N (#9 has to be Y), and the patient must be able to self-propel in the base being given. Suggested additional information required would be: What is the patient using now? What are you going to put him or her in and why won’t a K0004 meet the patient’s needs? This base requires specific information relating to what is needed that is not available on a K0004 for ADLs (activities of daily living) that the patient performs in the chair (this base specifically requires ADLs both inside and outside the home).

The best way to describe this is to tell exactly what the patient does during the day. The person who requires a wheelchair does the same things you do only from a wheelchair. If the user has been in an ultra lightweight, specify this and state that if he is changed to a lower-level base, it will take away independence.

Adult Manual Tilt In Space (E1161)
There are codes for pediatric manual tilts that are also accepted by Medicare and would require the same type of information. The E1161 is a manual tilt-in-space wheelchair, and it too is in the category of inexpensive/routinely purchased equipment. It can be purchased up front or rented to maximum allowable time.

The most important notation shows why a standard base with a manual recline would not meet the patient’s needs. For multiple reasons, the need for specialty seating and positioning is the key to getting reimbursed for a tilt in space. Time up in the chair, spasticity, and fixed-hip angle are some of the factors. The assistance of a good PT/OT who understands tilt in space is important for processing the correct paperwork.

This base can go to ADMC as well. The CMN should have #1=Y; #5 has to be completed; #8 can be N or D; #9 is usually N or D (although, in some newer models, patients can self propel). In most situations where these types of bases are needed, the patient is totally dependent, and proper positioning, pressure relief, respiratory, feeding, and other issues take precedence over any patient attempts at independent propulsion.

Remember to check the CMN before billing and make sure it is correct for payment. You or anyone with a financial link to your company is not allowed to change or complete any of part B on the CMN. The suggested answers are provided so that members of your billing staff know not to bill without having the physician correct the CMN—or if the patient does not meet requirements for the base you are providing. If that is the case, decide whether you are going to do an ABN or not provide that specific equipment without additional information.

Part A of the CMN can be completed by the supplier; the initial date is the date of service (or prior to), and does not have to be the date of delivery. I often see an initial date after the date of the physician’s signature, which indicates it was added after the physician signed the CMN (which should not be done and would also cause a denial statement of “no order on file”).

On part B of the CMN, the most common problem is the physician not completing the length of need and ICD-9 areas. This can be addressed by sending a “confirmation of verbal/fax or written order” with the CMN. If you receive an order relating to an HME item via the phone from the discharge planner, social worker, or nurse, write down the referral source’s full name, title, phone number, the date and time of the call, and exactly what is being ordered. Ask what the ICD-9 code is and how long the patient will need the item. When you send your CMN, include a copy of your order intake with all this information included; or write up a “confirmation of verbal order” that restates what you received. You can not lead the physician, but you can repeat what was told to your customer service on order intake.

Part C of the CMN needs to be completed “before” the physician signs the CMN. Unless you are sending the CMN to ADMC, the only items required are a: brief description of the base and accessories that will be billed; your charge and Medicare’s allowable. You do not have to put a “detailed” description on each item.

The physician or person ordering the item—physician assistant (PA) or licensed nurse practitioner (LNP)—is the person who has to sign the CMN. If a PA or LNP is the person caring for the patient, he can write the order and sign/date the CMN. They must have their own UPIN.

The 1500 form needs to be checked before billing as well. You would be surprised how many rejections are received just for writing the wrong HIC number or leaving block 11 blank. ICD-9 and HCPC codes need to be correct for date of service. A good reference for HCPC is now on the SADMERC Web site (go to www.pgba.com, click on SADMERC, then click on durable medical equipment coding system). This is an excellent site for searching for specific codes or items by description or code. It also connects to the fee schedules to quickly give you the allowable in your specific state.

The new LCD policies with the DMERCs have lists of ICD-9 codes that are specific to individual policies. A good Web site for ICD-9 lookups can be found at www.cms.hhs.gov/medlearn/icd9code.asp.

Peggy Walker, RN, assists members of US Rehab and Van G. Miller & Associates with reimbursement questions relating to Medicare, Medicaid, and private insurance. She worked for the Region C DMERC and assisted in the development of medical review criteria for wheelchairs, CPMs, and many other medical policies. Walker was lead nurse in the DMERC’s postpay review area and conducted supplier reviews and audits. She can be reached via e-mail: walkerp321@aol.com.